Abdominoperineal Excision: Technical Challenges in Optimal Surgical and Oncological Outcomes after Abdominoperineal Excision for Rectal Cancer

Personalized Decisional Algorithms for Soft Tissue Defect Reconstruction after Abdominoperineal Resection for Low-Lying Rectal Cancers

BACKGROUND

Abdominoperineal resection (APR)-the standard surgical procedure for low-lying rectal cancer (LRC)-leads to significant perineal defects, posing considerable reconstruction challenges that, in selected cases, necessitate the use of plastic surgery techniques (flaps).

PURPOSE

To develop valuable decision algorithms for choosing the appropriate surgical plan for the reconstruction of perineal defects.

METHODS

Our study included 245 LRC cases treated using APR. Guided by the few available publications in the field, we have designed several personalized decisional algorithms for managing perineal defects considering the following factors: preoperative radiotherapy, intraoperative position, surgical technique, perineal defect volume, and quality of tissues and perforators. The algorithms have been improved continuously during the entire period of our study based on the immediate and remote outcomes.

RESULTS

In 239 patients following APR, the direct closing procedure was performed versus 6 cases in which we used various types of flaps for perineal reconstruction. Perineal incisional hernia occurred in 12 patients (5.02%) with direct perineal wound closure versus in none of those reconstructed using flaps.

CONCLUSION

The reduced rate of postoperative complications suggests the efficiency of the proposed decisional algorithms; however, more extended studies are required to categorize them as evidence-based management guide tools.

Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta-analysis

A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure (MC) following abdominoperineal surgery (AS) and pelvic exenteration (PE) of anal and rectal cancers. Inclusive literature research till April 2023 was done and 2008 interconnected researches were revised. Of the 20 picked researches, enclosed 2972 AS and PE of anal and rectal cancers persons were in the utilized researchers' starting point, 1216 of them were utilizing VRAM flap, and 1756 were primary closure (PC). Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of VRAM flap in treating AS and PE of anal and rectal cancers by the dichotomous approach and a fixed or random model. VRAM flap had significantly lower PWCs (OR, 0.64; 95% CI, 0.42-0.98, p < 0.001), and major PWCs (OR, 0.50; 95% CI, 0.32-0.80, p = 0.004) compared to PC in AS and PE of anal and rectal cancers persons. However, VRAM flap and PC had no significant difference in minor PWCs (OR, 1; 95% CI, 0.54-1.85, p = 1.00) in AS and PE of anal and rectal cancer persons. VRAM flap had significantly lower PWCs, and major PWCs, however, no significant difference was found in minor PWCs compared to PC in AS and PE of anal and rectal cancers persons. However, caution needs to be taken when interacting with its values since there was a low sample size of most of the chosen research found for the comparisons in the meta-analysis.

Postoperative MRI Findings Following Conventional and Extralevator Abdominoperineal Excision in Low Rectal Cancer

Aim: The disparity in outcomes for low rectal cancer may reflect differences in operative approach and quality. The extralevator abdominoperineal excision (ELAPE) was developed to reduce margin involvement in low rectal cancers by widening the excision of the conventional abdominoperineal excision (c-APE) to include the posterior pelvic diaphragm. This study aimed to determine the prevalence and localization of inadvertent residual pelvic diaphragm on postoperative MRI after intended ELAPE and c-APE. Methods: A total of 147 patients treated with c-APE or ELAPE for rectal cancer were included. Postoperative MRI was performed on 51% of the cohort (n = 75) and evaluated with regard to the residual pelvic diaphragm by a radiologist trained in pelvic MRI. Patient records, histopathological reports, and standardized photographs were assessed. Pathology and MRI findings were evaluated independently in a blinded fashion. Additionally, preoperative MRIs were evaluated for possible risk factors for margin involvement. Results: Magnetic resonance imaging-detected residual pelvic diaphragm was identified in 45 (75.4%) of 61 patients who underwent ELAPE and in 14 (100%) of 14 patients who underwent c-APE. An increased risk of margin involvement was observed in anteriorly oriented tumors with 16 (22%) of 73 anteriorly oriented tumors presenting with margin involvement vs. 7 (9%) of 74 non-anteriorly oriented tumors (p = 0.038). Conclusion: Residual pelvic diaphragm following abdominoperineal excision can be depicted by postoperative MRI. Inadvertent residual pelvic diaphragm (RPD) was commonly found in the series of patients treated with the ELAPE technique. Anterior tumor orientation was a risk factor for circumferential resection margin (CRM) involvement regardless of surgical approach.

A meta-analysis of low Hartmann's procedure versus abdominoperineal resection for non-restorative treatment of rectal cancer

BACKGROUND

Non-restorative surgery for rectal cancer is indicated in patients with comorbidities, advanced disease and poor continence. The aim of this meta-analysis was to compare the postoperative morbidity of Hartmann's procedure (HP) with that of extrasphincteric and intersphincteric abdominoperineal resection (APR) in the treatment of rectal cancer.

METHODS

The Medline, Embase and Cochrane databases were searched for publications comparing postoperative morbidity of HP and APR. The incidence of overall surgical complications, pelvic-perineal complications and pelvic abscess was analysed as primary endpoints. Readmissions requiring reintervention and postoperative mortality were also compared.

RESULTS

A cumulative analysis showed a significantly higher rate of overall complications (odds ratio (OR) 0.553, 95% confidence interval (CI) 0.320 to 0.953 and P value 0.033) and pelvic-perineal complications (OR 0.464, 95% CI 0.250 to 0.861 and P value 0.015) after APR. The incidence of isolated pelvic abscess formation was significantly higher after HP (OR 2.523, 95% CI 1.383 to 4.602 and P value 0.003). A subgroup analysis of intersphincteric APR compared with HP did not show any significant difference in the incidence of overall complications, pelvic-perineal complications or pelvic abscess formation (P values of 0.452, 0.258 and 0.100, respectively). There was no significant difference in readmissions, reinterventions and mortality after HP and APR (P 0.992, 0.198 and 0.151).

CONCLUSION

An extrasphincteric APR is associated with higher overall and pelvic-perineal complications and may be reserved for tumours invading the anal sphincter complex. In the absence of sphincter involvement, both HP and intersphincteric APR are better alternatives with comparable morbidity.

Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection

The surgical management of low-lying rectal cancer, within 5 cm from the anal verge (AV), is challenging due to the possibility, or not, to preserve the anus with its sphincter muscles maintaining oncological safety. The standardization of total mesorectal excision, the adoption of neoadjuvant chemoradiotherapy, the implementation of rectal magnetic resonance imaging, and the evolution of mechanical staplers have increased the rate of anus-preserving surgeries. Moreover, extensive anatomy and physiology studies have increased the understanding of the complexity of the deep pelvis. Intersphincteric resection (ISR) was introduced nearly three decades ago as the ultimate anus-preserving surgery. The definition and indication of ISR have changed over time. The adoption of the robotic platform provides excellent perioperative results with no differences in oncological outcomes. Pushing the boundaries of anus-preserving surgeries has risen doubts on oncological safety in order to preserve function. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.

Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis

Simple Summary

Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer (mainly anal and rectal cancers) require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, Group C comparing PC and VRAMf in PE. The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total and major perineal wound complications. PC was associated with a decrease in total and major perineal complications in Group C.

Abstract

Background. Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers). Methods. We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE. Results. Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43–0.71; p < 0.01/Group B: OR 0.54, CI 0.17–1.68; p = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35–0.68; p < 0.001/Group B: OR 0.38, 95% CI 0.12–1.17; p < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39–4.35; p < 0.01) and major (OR 1.67, 95% CI 0.90–3.08; p = 0.1) perineal complications in Group C. Conclusions. Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.

Transperineal minimally invasive APE: preliminary outcomes in a multicenter cohort

Background

Abdominoperineal excision (APE) for rectal cancer is associated with a relatively high risk of positive margins and postoperative morbidity, particularly related to perineal wound healing problems. It is unknown whether the use of a minimally invasive approach for the perineal part of these procedures can improve postoperative outcomes without oncological compromise. The aim of this study was to evaluate the feasibility of minimally invasive transperineal abdominoperineal excision (TpAPE)

Methods

This multicenter retrospective cohort study included all patients having TpAPE for primary low rectal cancer. The primary endpoint was the intraoperative complication rate. Secondary endpoints included major morbidity (Clavien–Dindo ≥ 3), histopathology results, and perineal wound healing.

Results

A total of 32 TpAPE procedures were performed in five centers. A bilateral extralevator APE (ELAPE) was performed in 17 patients (53%), a unilateral ELAPE in 7 (22%), and an APE in 8 (25%). Intraoperative complications occurred in five cases (16%) and severe postoperative morbidity in three cases (9%). There were no perioperative deaths. A positive margin (R1) was observed in four patients (13%) and specimen perforation occurred in two (6%). The unilateral extralevator TpAPE group had worse specimen quality and a higher proportion of R1 resections than the bilateral ELAPE or standard APE groups. The rate of uncomplicated perineal wound healing was 53% (n = 17) and three patients (9%) required surgical reintervention.

Conclusions

TpAPE seems to be feasible with acceptable perioperative morbidity and a relatively low rate of perineal wound dehiscence, while histopathological outcomes remain suboptimal. Additional evaluation of the viability of this technique is needed in the form of a prospective trial with standardization of the procedure, indication, audit of outcomes and performed by surgeons with vast experience in transanal total mesorectal excision.